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03/20/2006 14:53 209 38 <br /> ENVIRONWNTAL AllI1 rAGE o1i+1? <br /> tllvr IED PRMRAM CONSOLMATED FORM <br /> 1g1tGRa STORAGE TANY, <br /> CERTIFICATION Ok`lNSTALLA13ON/MODIFICATION <br /> (Ono-form pa Project) <br /> 1. FACILITY <br /> WORMATION ,. <br /> Fm:fLirf I Ps,"cv Useody) <br /> BUS—ESS NAME(Sumr,ea Facifliy Marne or DBA-rAl1nR Bttstnrsa�s) <br /> ZHUSWNE%Soft ADORE99 <br /> Ja. INSTALLATION J PV1aD>t�'1CAT10N' ROJECT DIESON <br /> TYPE OF PROtFa(Chet&at 4"L WORK Arp>•HORI2ED t3NTXlt PERVITT <br /> d 1.TANK NSTALLAVON OR REPLACEMENT (Number or bate) <br /> �j 2,PfPrN(3 INSTALLATIDN OR REPLACEMENT <br /> a <br /> A.sU&tP nv <br /> INSTALLATION ox cstxr <br /> p s.UNDER DVENSER CONTAINMENT U*TALLATraN ors REPLACEMENT <br /> ..(7TFi>:R axac. <br /> Dt scRtPTrON oP WORK® cERT[F1fi17 ,.� ire <br /> 'fit S�`w �e"OL ti.oP� 'T <br /> � 63tku�-' W9Pt'' t.tE�'• "�T c.�S 't'� �' ,��- <br /> M. CONTRACTOR INFO TION <br /> V,41ME Of co>r"fRACTOR WHO PERFORMED rN3TALLAT ON(MOUTTCATION <br /> CO`rTRACTORLICENSG0 °Ma1` 1CCCERTrFrCATrgN <br /> IV. CERTIFICATION <br /> I certify that the irttomittiom provided helrew is true,accurate,*ad that the Mewing Conditions have bma satisfied: <br /> Inc installer has rAct the requirements go forth in 23 CCR§2715,subtiMsions(g)and(h). <br /> The underground storage tank, any primary Piping, and any seoondwy containment wad installed according to applicable <br /> voluntary consensus standards and arty manufaoturer's written.installation instructions. <br /> All work tilted in the Manufacturer's installation checklist has bcM eMttpleted, <br /> The install n has been'Inspected 4adAMnuved by the local&9MY,o1'if motred by the local agency,inspected and certified <br /> e ticatlon a ericnce with underground sAomottanks atom installations. <br /> 510. OR AQFNT 484. P ON6Let— <br /> +!� <br /> TMIER'S NAME(print) '"°' CERTIFIFR'S TIrMF.; <br /> NAME OF CERTIFIER'S EMPLOYER(DBA) ... C51tT1F115R'$RELAYrON9lr1P TO TANK OWNER <br /> r Q 1.TANK OWNER ❑ 2.TANK OPERATOR <br /> n AJ S c2r a p 3, N'rltncroR p 4.r>zaPEtttY owNrtR <br /> R j amgR ALrmo;ti2CD ABENT Or TANTS,OWNER <br /> CACP L'ST:C Rev.(1212047).112 asvw,uat8ocs.erR <br />